AN APPROACH TO

HYPERTENSION
4TH YEAR

DR/
ABDELWAHAB HASSAN ABDELWAHAB
ASSISTANT PROFESSOR INTERNAL MEDICINE
FOM, TU
2018
 PROBLEM MAGNITUDE

• Hypertension( HTN) is the most common primary diagnosis.

• ~ 35 million office visits are as the primary diagnosis of HTN.

• ~ 50 million or more Americans have high BP.

• Worldwide prevalence estimates for HTN may be as much as 1 billion (20%).

• ~ 7.1 million deaths per year may be attributable to hypertension.

 Definition

• Definition :

A systolic blood pressure (SBP) ≥ 140 mmHg and/or A diastolic

(DBP) ≥ 90 mmHg.

Based on the average of two or more properly measured, seated

BP readings.

On each of two or more office visits.

 Accurate Blood Pressure
Measurement

• The equipment should be regularly inspected and validated.

• The operator should be trained and regularly retrained.
• The patient must be properly prepared and positioned and
seated quietly for at least 5 minutes in a chair.
• The auscultatory method should be used.
• Caffeine, exercise, and smoking should be avoided for at
least 30 minutes before BP measurement.
• An appropriately sized cuff should be used.
 BP Measurement

• At least two measurements should be made and the average

recorded.

• Clinicians should provide to patients their specific BP numbers

and the BP goal of their treatment.
JNC 7 Classification of HTN
 2013 ESH/ESC Guidelines for the management of arterial hypertension

Definitions and classification of office BP levels (mmHg)*

Hypertension:
SBP >140 mmHg ± DBP >90 mmHg

Category Systolic Diastolic

Optimal <120 and <80

Normal 120–129 and/or 80–84

High normal 130–139 and/or 85–89

Grade 1 hypertension 140–159 and/or 90–99

Grade 2 hypertension 160–179 and/or 100–109

Grade 3 hypertension ≥180 and/or ≥110

Isolated systolic hypertension ≥140 and <90

* The blood pressure (BP) category is defined by the highest level of BP, whether systolic or diastolic. Isolated systolic
hypertension should be graded 1, 2, or 3 according to systolic BP values in the ranges indicated.

The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
Medical Education & Information – for all Media, all Disciplines, from all over the World
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 Comparison of Recent
Guideline Statements
JNC 8 ESH/ESC AHA/ACC ASH/ISH
>140/90
Threshold >140/90 < 60 yr Eldery SBP >160 >140/90 <80 yr
for Drug Rx >150/90 >60 yr Consider SBP >140/90 >150/90 >80 yr
140-150 if <80 yr

B-blocker No Yes No No
First line Rx

Initiate Therapy >160/100 "Markedly >160/100 >160/100

w/ 2 drugs elevated BP"
Follow-up based on initial BP measurements for adults*

www.nhlbi.nih.gov *Without acute end-organ damage

 Prehypertension
• Prehypertension : SBP 120 -139 mmHg and/or DBP 80 - 89
mmHg .

• Prehypertension is not a disease category rather a designation

for individuals at high risk of developing HTN.
 Pre-HTN

• Pre-HTN Individuals who are pre-hypertensive are not

candidates for drug therapy, BUT, Should be firmly and
unambiguously advised to practice lifestyle modification(NICE).

• Those with pre-HTN, who also have diabetes or kidney disease,

drug therapy is indicated IF a trial of lifestyle modification fails to
reduce their BP to 130/80 mmHg or less(NICE).
 Isolated Systolic Hypertension

• A systolic blood pressure (SBP) ≥140 mmHg and/or A diastolic (DBP) < 90 mmHg.

• SBP should be primarily considered during treatment and not just diastolic BP.

• Systolic BP is more important cardiovascular risk factor after age 50.

• Diastolic BP is more important before age 50.

 Hypertensive Crises

• Hypertensive Urgencies :
No progressive target-organ dysfunction. (Accelerated Hypertension)

• Hypertensive Emergencies :
Progressive end-organ dysfunction. (Malignant Hypertension)
 Hypertensive Urgencies

• Hypertensive Urgencies : Severe elevated BP in the upper

range of stage II hypertension. Without progressive end-organ
dysfunction.

• Examples : Highly elevated BP without severe headache, shortness of

breath or chest pain.

• Usually due to under-controlled HTN.

 Hypertensive Emergencies

• Hypertensive Emergencies : Severely elevated BP (>180/120 mmHg).

With progressive target organ dysfunction.

• Require emergent lowering of BP.

• Examples : Severely elevated BP with :

- Hypertensive encephalopathy
- Acute left ventricular failure with pulmonary edema
- Acute MI or unstable angina pectoris
- Dissecting aortic aneurysm
 Types of Hypertension

Primary HTN : Secondary HTN :

Also known as essential HTN. Less common cause of HTN (~ 5%).

Accounts for ~ 95% cases of Secondary to other potentially

HTN. rectifiable causes.

No universally established
cause known.
Causes of Secondary HTN
• Common • Uncommon

• Intrinsic renal disease • Pheochromocytoma

• Reno-vascular disease • Glucocorticoid excess
• Mineralocorticoid excess • Coarctation of Aorta
• Sleep Breathing disorder • Hyper/hypothyroidism
Secondary HTN - Clues in Medical History:

• Onset :

- at age < 30 yrs ( Fibromuscular dysplasia) or > 55 (athelosclerotic renal artery stenosis),
sudden onset (thrombus or cholesterol embolism).

• Severity:
- Grade II, unresponsive to treatment.

• Episodic, headache and chest pain/palpitation (pheochromocytoma, thyroid dysfunction).

• Morbid obesity with history of snoring and daytime sleepiness (sleep disorders)
 Secondary HTN - clues on Exam:

• Pallor, edema, other signs of renal disease.

• Abdominal bruit especially with a diastolic component (reno-vascular).

• Truncal obesity, purple striae, buffalo hump (hypercortisolism)

Secondary HTN - Clues on Routine Labs:

• Increased creatinine, abnormal urinalysis (renovascular and

renal parenchymal disease).

• Unexplained hypokalemia (hyperaldosteronism).

• Impaired blood glucose (hypercortisolism).

• Impaired TFT (Hypo/hyperthyroidism)

Secondary HTN - Screening Tests :

 Renal Parenchymal Disease:

• Common cause of secondary HTN (2-5%).

• HTN is both cause and consequence of renal disease.

• Multifactorial cause for HTN including disturbances in Na/water

balance, vasodepressors/ prostaglandins imbalance.

• Renal disease from multiple etiologies.

Secondary HTN - Screening Tests :

 Renovascular HTN:

• Atherosclerosis 75-90% ( more common in older patients).

• Fibromuscular dysplasia 10-25% (more common in young patients,
especially females).
• Other Aortic/renal dissection
• Takayasu’s arteritis
• Thrombotic/cholesterol emboli
• CVD
• Post transplantation stenosis
• Post radiation
Complications of Prolonged Uncontrolled HTN:

• Changes in the vessel wall leading to vessel trauma and

arteriosclerosis throughout the vasculature

• Complications arise due to the “target organ” dysfunction and

ultimately failure.

• Damage to the blood vessels can be seen on fundoscopy.

What is end organ damage in Hypertensive
emergency?
• Fibrinoid necrosis of BV & poor blood supply to vital organs
• MI/ Unstable angina
• Left ventricular failure ( cardiomyopathy)
• Aortic dissection/ rupture
• Acute renal failure
• Bilat. retinal hemorrhage, exudates, papilloedema (Malignant)
• Hypertensive encephalopathy (cofusion seizure, coma) (Malignant HTN)
• Eclempsia in pregnant females
• Microangiopathic hemolytic anemia (Malignant HTN)
• 90% die in 1 yr. (Malignant HTN)
 Complications of Prolonged Uncontrolled HTN:

Target Organs : Effects on The Kidneys:

- CVS (Heart and Blood Vessels) • Glomerular sclerosis leading to impaired

- The kidneys kidney function and finally end stage kidney
- Nervous system disease.
- The Eyes • Ischemic kidney disease especially when
renal artery stenosis is the cause of HTN
Effects On CVS :
Nervous System:
• Ventricular hypertrophy, dysfunction and failure.
• Arrhythmias, Coronary artery disease, • Stroke, intracerebral and subaracnoid
• Acute MI hemorrhage.
• Arterial aneurysm, dissection, and rupture. • Cerebral atrophy and dementia
 Complications, cont.

The Eyes:
Stage I- Arteriolar Narrowing
• Retinopathy, retinal hemorrhages and
impaired vision.
• Vitreous hemorrhage, retinal Stage II- AV Nicking
detachment
• Neuropathy of the nerves leading to
extraoccular muscle paralysis and Stage III- Hemorrhages (H), Cotton Wool Spots and
dysfunction Exudates (E)

Stage IV- Stage III + Papilledema

 Retina Normal and Hypertensive Retinopathy

A B

Normal Retina Hypertensive Retinopathy A: Hemorrhages

B: Exudates (Fatty Deposits)
C: Cotton Wool Spots (Micro
Strokes)
Stage I- Arteriolar Narrowing

Arteriolar Narrowing
Stage II- AV Nicking

AV
AVNicking
Nicking

AV Nicking
AV Nicking
Stage III- Hemorrhages (H), Cotton Wool Spots
and Exudats (E)
H

E
Stage IV- Stage III+Papilledema
Patient Evaluation Objectives

(1) To assess lifestyle and identify other cardiovascular risk

factors or concomitant disorders that may affect prognosis
and guide treatment

(2) To reveal identifiable causes of high BP

(3) To assess the presence or absence of target organ damage

and CVD
(1) Cardiovascular Risk factors

• Hypertension
• Cigarette smoking
• Obesity (body mass index ≥30 kg/m2)
• Physical inactivity
• Dyslipidemia
• Diabetes mellitus
• Microalbuminuria or estimated GFR <60 mL/min
• Age (older than 55 for men, 65 for women)
• Family history of premature cardiovascular disease (men
under age 55 or women under age 65)
(2) Identifiable Causes of HTN

• Sleep apnea
• Drug-induced or related causes
• Chronic kidney disease
• Primary aldosteronism
• Renovascular disease
• Chronic steroid therapy and Cushing’s syndrome
• Pheochromocytoma
• Coarctation of the aorta
• Thyroid or parathyroid disease
(3) Target Organ Damage

• Heart
Left ventricular hypertrophy
Angina or prior myocardial infarction
Prior coronary revascularization
Heart failure
• Brain
Stroke or transient ischemic attack
• Chronic kidney disease
• Peripheral arterial disease
• Retinopathy
History
• Angina/MI Stroke: Complications of HTN, Angina may
improve with B-blockers
• Asthma, COPD: Preclude the use of B-blockers
• Heart failure: ACE inhibitors indication
• DM: ACE preferred
• Polyuria and nocturia: Suggest renal impairment
History-contd.
• Claudication: May be aggravated by B-blockers, atheromatous
RAS may be present
• Gout: May be aggravated by diuretics
• Use of NSAIDs: May cause or aggravate HTN
• Family history of HTN: Important risk factor
• Family history of premature death: May have been due to
HTN
History-contd.
• Family history of DM : Patient may also be Diabetic
• Cigarette smoker: Aggravate HTN, independently a risk factor
for CAD and stroke
• High alcohol: A cause of HTN
• High salt intake: Advice low salt intake
Examination
• Appropriate measurement of BP in both arms
• Optic fundi
• Calculation of BMI ( waist circumference also may be useful)
• Auscultation for carotid, abdominal, and femoral bruits
• Palpation of the thyroid gland.
Examination-contd.
• Thorough examination of the heart and lungs
• Abdomen for enlarged kidneys, masses, and abnormal aortic
pulsation
• Lower extremities for edema and pulses
• Neurological assessment
Investigations for HTN
• Ambulatory BP monitoring
• CBC ( Polycythemia, ) , ESR
• Serum Na, K, Ca, Cl, HCO3, Blood sugar, Urea , creatinine
• ECG
• Echocardiography (for sign of heart failure)
• Urine for protein/blood, Renal Ultrasonography( kidney and adrenal tumour)
• Chest X-RAY ( for heart size shape and coarctation aorta, fluid overload)
• Fundoscopy
• TSH, Imaging and tests for Cushing ds, PTH, Screen for pheocromocytoma
• Serum Lipids
• Drugs screen (cocaine)
Management of HTN
 Goals of Treatment
• Treating SBP and DBP to targets that are <140/90 mmHg

• Patients with diabetes or renal disease, the BP goal is <130/80 mmHg

• The primary focus should be on attaining the SBP goal.

• To reduce cardiovascular and renal morbidity and mortality

Benefits of Treatment
• Reductions in stroke incidence, averaging 35–40 %

• Reductions in MI, averaging 20–25 %

• Reductions in HF, averaging >50 %

 2013 ESH/ESC Guidelines for the management of arterial hypertension

Lifestyle changes for hypertensive patients

Recommendations to reduce BP and/or CV risk factors
Salt intake Restrict 5-6 g/day

Moderate alcohol intake Limit to 20-30 g/day men,

10-20 g/day women

Increase vegetable, fruit, low-fat dairy intake

BMI goal 25 kg/m2

Waist circumference goal Men: <102 cm (40 in.)*

Women: <88 cm (34 in.)*

Exercise goals ≥30 min/day, 5-7 days/week

(moderate, dynamic exercise)

Quite smoking
* Unless contraindicated. BMI, body mass index.

The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
Medical Education & Information – for all Media, all Disciplines, from all over the World
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SUMMARY [JNC 8 Recommendations]
• BP: Recommended goal of < 140/90

• Reassess treatment monthly

• Avoid ACEI/ARB combination

• Stage 1 hypertension (systolic BP 140-159 mm Hg or diastolic BP 90-99 mm Hg): Can be treated with

lifestyle modifications and, if target BP not achieved then add a thiazide diuretic if no contraindication(like

black race)

• Stage 2 hypertension (systolic BP >160 mm Hg or diastolic BP >100 mm Hg): Treated with drug Start with

thiazide diuretic /ACE inhibitor/ARB. If goal BP not achieved increase the dose. If after a month BP higher

than the goal, then add on calcium channel blocker .

• Patients who fail to achieve BP goals: Medication doses can be increased and if still after a month target not

achieved then add 2nd drug from a different class. If 2nd drug also fails to control , add 3rd agent but do not

remove other agents (unless side effects noticed)

 Other medications for hypertensive patients

For primary prevention of vascular disease :

(1) Aspirin: use for all patients unless contraindicated

(2) Statin: use sufficient doses to reach targets if patient is aged up to at least 80 years with a total
cholesterol concentration 3.5 mmol/l (Targets for lipid : Total Cholestrol <4.0mmol/l or LDL
<2.0mmol/l)

(3) Vitamins: no benefit shown, do not prescribe

THANK YOU